Monday, 23 June 2008

In just over a year, the European Working Time Directive (EWTD) comes into full force for junior doctors. The directive will state that it will be illegal for our employers to make us work more than 48 hours each week. As things stand today, we are meant to be working a maximum of 56 hours – at least, in theory.

The general consensus among the junior and senior doctors that I speak to is that the EWTD is a bad thing. It’s a bad thing because it reduces the amount of experience that doctors in training have, it reduces how often we are exposed to and have to deal with a given situation. In the long run, it will lead to consultants being less qualified and less capable than they used to be, and thins will have a damaging effect on patient care.

The other, more pressing reason why the EWTD is a bad thing is because there will be a lack of continuity of care for the patients. In the old days, a patient coming into hospital would be seen by two or three doctors during their hospital stay. The EWTD means that the same patient could be seen by six, seven or more doctors. The said doctors won’t necessarily know all the details about the patient or what their colleagues have said or done, so as a result, things get duplicated or omitted and patient care suffers.

There has been plenty written about the problems implementing the EWTD and there have been calls from manyindividuals and organisations (including the excellent Remedy UK) for doctors to be made exempt from the EWTD, that is, that we should be working more than 48 hours a week.

I disagree with this.

I take the minority view that the EWTD is actually a good thing and will improve things for doctors and, more importantly, for our patients. Let me try and explain.

First of all, let’s not lose sight of what we are talking about here. At the moment, we are meant to work no more than 56 hours per week, the EWTD makes it illegal for junior doctors to work more than 48 hours every week. Given that the standard working pattern in this country is 9am to 5pm, then we are talking about a reduction from working 7 days a week to working 6 days a week.

Working 6 days a week is plenty of time. Working 6 days a week for nine years (for hospital specialties) is a long enough apprenticeship. (Remember, that all this comes after spending five years at medical school). After working 6 days a week for nine years, I think that doctors would be confident that they could deal with just about anything that their specialty could throw at them.

Working 6 days a week is plenty, PROVIDED THAT YOU ARE BEING TRAINED.

This is the real problem that medical training faces, if you ask me. As a junior doctor working in General Medicine or General Surgery, I spent so little of my time learning useful stuff, it was untrue. The vast majority of my time was taken up with form-filling, chasing results, phlebotomy, re-writing drug charts, cannulation and arranging discharges from hospital. As a proportion of the average working day, the time I spent learning about and trying to understand the management of the patients I was looking after was small. The time I actually spent managing the patients myself and taking decisions was minimal. The consultants were pretty unhelpful (sometimes spectacularly so) when I tried to find ways of improving my training.

The sad fact is that most of the time I was at work, I was learning little that was new. Cutting back on this time won’t make me a worse doctor, provided I still get experience of the important parts of clinical decision making and management.

The surgeons are talking about the cuts in their operating times and the consequent reduction in their experience. This may be true, but this has little to do with the EWTD and much more to do with NHS hospitals trying to save money.

It goes like this. The hospital gets paid by the Primary Care Trust (PCT) for each operation done at the hospital. A senior consultant can do an operation much faster than a junior registrar or SHO. So, in order to make more money, the hospital gets the senior consultants to do the vast majority of the operations. Good for the hospital, good for the patients, bad for the training of junior doctors.

I very rarely see the junior surgical doctors in theatres, but I remember as a medical student, the SHOs and SpRs had their own theatre lists of simple operations. This doesn’t happen anymore and I think the real reason why our surgeons aren’t getting the training they want is nothing to do with the EWTD and everything to do with the bottom line.

The message is simple: we juniors want to have proper training when we are at work. We want to be interpreting CT scans and making decisions based on them (under appropriate supervision, of course), we want to be diagnosing and treating medical emergencies, we don’t want to be filling endless reams of discharge forms and other paperwork.

The continuity of care issue is a tougher nut to crack, in my opinion. It is much better if all the doctors, nurses and paramedical staff know everything about each patient and understand what the plans for that individual are. However, this ideal is very difficult to achieve with the shift system that the EWTD necessitates. I don’t think that going back to the old “the same doctor will be here all the time” system is the way forward.

Let’s not forget the downsides to working very, very long hours.

I’m young enough to have avoided the days when junior doctors started work on Friday morning and didn’t leave until Monday evening, but I’m old enough to have done runs of 15hr and 24hr shifts and let me tell you, they are far from fun.

You can do one or two long shifts and still function quite well, but after five, six or seven on consecutive days, it can become a nightmare. You rarely get chance to eat properly on these shifts and you become ridiculously tired because you’ve hardly had any sleep. What happens is that you become really emotional, really bad-tempered and after a while you get to a point where your brain becomes like mashed potato. You can’t think straight and you find it difficult to summon the energy to even move.But your pager doesn’t stop going. The patients don’t stop coming in and they all have to be seen and treated because they all need your help. So, I ask you, when you get called to see little Mrs Robertson, the 83 year old lady from a nursing home with multiple medical problems who’s come in because she’s “not eating much” and all your body wants to do is eat something and lie down for a bit; are you really going to pick up the super-added pneumonia that she has on top of her worsening heart failure? Are you? Really?

The worst thing about working really long hours is that you become really resentful. You become resentful of the hospital, resentful of your decision to become a doctor and, worse of all you become resentful towards the patients. You start to feel animosity towards the very people you’re supposed to be helping and that is a really horrible thought situation to be in. You feel awful about yourself for thinking those thoughts, but you can’t stop yourself because, ultimately, what is standing between you and the sleep that you crave are the ill patients you have to look after.

There are huge rafts of evidence that point to the fact that tired doctors make bad decisions and the care of patients suffers. I think the opponents of the EWTD should be very careful what they wish for. Like I say, working six days a week is enough.

I love my job as a junior anaesthetist. Since I left General Medicine, it’s been a breath of fresh air and I’m really enthusiastic and passionate about what I do and about caring for my patients. I think a huge part of the reason for this is the way that anaesthetic training is set up.

In the last ten months, I’ve given over 300 anaesthetics to patients. In that time I have had outstanding support from my seniors, but have been given enough space to get on and do things by myself. The paperwork I have to do is minimal and is to-the-point and useful and most importantly, people leave me alone to get on with my job. There’s no expectation that I should be in four places at the same time.

I’m working a 48-hr EWTD compliant(ish) rota and it means that I don’t go home feeling shattered and pissed-off with my job. I have the time and the inclination to do things outside the workplace and my life is much happier for it. I found myself looking up the route of the median nerve in my anatomy book after work last week, I would never have done that if I had to work more hours. I think all-in-all the training I’m getting in anaesthesia and the free-time that the EWTD allows is making me a better doctor, not a worse one.

I think the other medical specialties should look at the way training in anaesthesia is structured and take a leaf out of that book.

I don't think going back to the old ways is the best way. I do like the fact that I still feel I can love my job.

For a while I did on calls in Obs and Gynae where we got to sleep overnight - patients stopped being people I cared about and started being things stopping me sleeping.

The lack of continuity of care in medicine is perhaps due to filling rotas and a lack of medical team. The Team is dead - which means that when I admit people I don't get to follow them up by looking after them.

Your post reminded me of when I was going out with a medical house officer in the 90s. He worked the most disgusting hours. I remember when he worked from Friday evening till Monday evening. He was tired all of the time.

The WTD is one of the few directives that have come from the EU that I quite like.

I think you'll find that some doctors will choose to work more than 48 hours in a week (as is what happens in other job roles today), but that number will probably be really small.

A slight restructuring in the way Doctors are trained along with ensure the maximum number of graduates get jobs should mean the impact of the WTD in the medical world will be a positive rather than negative one.

When I was a surgical SHO in the mid 80s, I worked a 1 in 2 on call rota. In one year I did over a hundred each of appendicectomies, hernia repairs and varicose vein operations alone and un supervised. I did numerous leg amputations and circumcisions not to mention endless lumps, bumps and biopsies. When the hospital suggested changing to a 1 in 3 rota, all the surgical SHOs complained that this would reduce our operating time

When I realised that I didn't have the requisie personality disorder to become a surgeon, I switched to anaesthetics and got my FRCA. As a result of my exposure to both sides of the blood brain barrier I strongly believe that you can operate quite safely when you are tired as the adrenaline keeps you awake - you cannot however give an anaesthetic safely when you are tired because of the boring bit in the middle while the surgeon does his stuff.

So there are pros and cons of long hours - personally I think the EWTD will mean that future surgeons will have much less experience when they become consultants than the current group but there will be fewer anaesthetic disasters.

Have just come accross your blog. One of the best argued posts I have read on EWTD anywhere. The issues of training and service (i.e. paperwork) are often confused and with the EWTD , trusts may finally be forced to value the time of junior doctors.

Don't forget that the Calman reforms (specialist registrar reforms - ie, the last run to consultant) were vigorously opposed by many, but looking back on them now they standardised and raised the bar for training to CCST.

Please remember... doctors are getting paid a salary. If you are getting 'trained' and avoid all banal tasks (“form-filling, chasing results, phlebotomy, re-writing drug charts, cannulation and arranging discharges from hospital”) then what service are you providing? (I can hear the screams of protestation from here!) I’m afraid that no doctor is in a position to be able to be “interpreting CT scans and making decisions based on them and diagnosing and treating medical emergencies” from the start of their career and if they need to be trained “under appropriate supervision, of course” by a consultant for all of their available training time in a week (9-5, 6 days a week means not 1 night shift)then what service are they actually providing? Essentially that would mean 48 hours of training a week with no service provision for 9 years... utopia I agree but not really meriting current pay rates. That would be the same as being a student again maybe? At present there is a need for medical coverage in hospitals. The bill for the NHS is running somewhere over the £100 billion mark with over 60% going on salaries and wages. Im not sure the government or the public would tolerate doctors working for 9 years at current pay rates without doing some independent work over that time. In addition there is no good evidence to say that 48 hours working is safe and 49 hours is unsafe. There is evidence to say that TIRED workers are unsafe but no specifics about how may hours make a tired worker.... much purposeful and agenda loaded speculation exists however. (remember, the the EWTD was originally an economic bill !) Hospitals need to keep functioning and unfortunately there are few alternatives available without flooding the market with tens of thousands of consultants .. literally. This has so many problems with it that it really cannot be an option. Medicine is a hard career choice and maybe rightfully so…. patients deserve doctors who are the best. Unfortunately that means not just theoretical learning (glad to hear you found the energy to look up the route of the median nerve after your shift) but also a great deal of experience. One cannot substitute for the other and as an anaesthetist you are only going to be exposed to a handful of AAA’s over your training. The more you are in hospital the more you will see. There are a lot of people out there with funny agendas that are driving an intolerance of any discussion which could exempt doctors form working more than 48hours. This is actually discriminating against those who actually may want to.Working over 100 hours is stupid and cannot be advocated or returned to but some sensible debate is required (without unscientific propaganda and scare stories of planes crashing) over how many hours can be worked safely so that training can be maintained to a decent standard, so that the work force problems of the NHS can be fixed and so that junior doctors can be paid properly for the hard work that they do.

Anon: there are plenty of other things junior doctors do which are combined service and training rather than just service.

During my time on a plastic surgery firm, I did a lot of clinic and operating theatre time, where I began by assisting and learning the details of the operation and its followup, and then started doing some of the procedure (closing, grafting, etc) and doing followup on my own cases.

I'm currently an F2 on an emergency medicine term, and the training aspects are when I take a sick patient and manage them under supervision. The service aspects are when I see someone who's come in with a sore throat.